EMERGENCY MEDICAL CARE

AND
EMERGENCY ROOM
 Disaster

Any emergency that disrupts

normal community function
causing concern for the safety of
its citizens including their lives
and property.
 Types of disasters
• Natural disasters

• Manmade
 Scope and Practice of Emergency
Nursing
• Emergency management traditionally refers to
urgent and critical care needs; however, the ED has
increasingly been used for non-urgent problems,
and emergency management has broadened to
include the concept that an emergency is whatever
the patient or family considers it to be
• The emergency nurse has special training, education,
experience, and expertise in assessing and
identifying health care problems in crisis situations

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Scope and Practice of Emergency
Nursing

• Nursing interventions are accomplished

interdependently in consultation with or
under the direction of a physician, physician’s
assistant, or nurse practitioner

• The emergency room staff works as a team

5
 Priority Emergency Measures for
All Patients
• Make safety the first priority
– For patients, family and staff
• Preplan to ensure security and a safe environment
– Potential for violence in the ER
– May be related to emotional stress, substance abuse,
violent injuries
• Closely observe patient and family members in the event that
they respond to stress with physical violence
• Assess the patient and family for psychological function
• Documentation of consent
– If patient or next of kin unable to consent, nurse must
carefully document circumstances 6
Priority Emergency Measures for
All Patients (cont.)

• Patient and family-focused interventions

– Relieve anxiety and provide a sense of security
– Allow family to stay with patient, if possible, to
alleviate anxiety
– Provide explanations and information
– Provide additional interventions depending upon
the stage of crisis

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 Triage
• Triage (“to sort”) sorts patients by hierarchy based on the
severity of health problems and the immediacy with which
these problems must be treated
– Emergent, urgent, non life-threatening, fast track
– Emergency Severity Index (see table 69-2)
• The triage nurse collects data and classifies the illnesses and
injuries to ensure that the patients most in need of care do
not needlessly wait
• Protocols may be initiated in the triage area
• ED triage differs from disaster triage in that patients who are
the most critically ill receive the most resources, regardless of
potential outcome 8
 Triage
• Systematic approach to manage emergent or
urgent situations. Primary survey includes:
– Airway with cervical spine stabilization
– Breathing
– Circulation
– Disability (neurological)

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 Disaster planning
• Purpose
– To provide policy for response to both internal and external
disasters situations that may affect hospital staff,patients
and the community
– Identify responsibilities of individuals and departments in
the event
– Prime function is to minimize the resulting loss of
property, injuries, suffering and death that accompanies a
disaster
 The disaster difference
• Large number of people with different
severity levels
• Rapidly declining survival rates
• Narrow window of opportunity for
salvaged
• Disorganised and haphazard delivery of
health care if hospital itself is affected
 Planning
• At the site of disaster itself
• At the hospital-managing victims
• Disaster at the hospital itself
• Plans must be simple and
flexible. They should be made by
the people who are going to
execute them.”
george patton
 Goals of planning
• to control the large number of patients
and the resulting problems as good as
possible
• by enhancing the capacities of admission
and treatment,
• by treating patients based on the rules of
individual medicine
 Goals of planning
• by ensuring ongoing proper treatment
for all patients who where already there
• by a smooth handling of all additional
tasks caused by such an event.
• to give medical support the damage area
 Phases to be planned for
• activation phase

• Implementation
phase

• Recovery phase
 EMERGENCY ROOMS
ORGANIZATION: Triage area

TARGETS:
– To attend in priority patients with life-threatening
conditions or higher risk of complication.
– To improve medical care.
– To manage patients flow and decrease
overcrowding.
– To improve patient satisfaction and decrease overall length
of stay.

ESSENTIAL IN ANY EMERGENCY ROOM

 EMERGENCY ROOMS
ORGANISATION: Triage area

• Routine triage :
– syndromic approach or vital signs approach (depends of
skills, patients flow, material…)
– Triage area at ER entrance

• Massive influx:
– Large area prepared at ER entrance (empty and closed in
routine activity)
– Mass casualty incident guide line
 ROUTINE:
SYNDROMIC APPROACH
RED PATIENTS
PATIENT TO BE SEEN BY DOCTOR IMMEDIATELY: patients are critical and need immediate treatment
Direct to resuscitation room. Inform doctor and other nurses.
Registration is done after initial treatment.

 Any patient with shock or signs of early onset of shock (tachycardia, low blood pressure, poor
capillary refill, cool peripheries)
 Polytrauma (trauma with multiple injuries)
 High energy trauma
 Any bleeding (trauma or non-trauma) with impending shock
 Severe burns: Large area, burns to face or perineum, electrical or chemical burn, smoke inhalation
 Fracture or dislocation with neurovascular compromise
 Altered level of consciousness / coma
 Ongoing seizures
 Respiratory rate <9 or >20 in adult and/or cyanosis
 Severe chest pain
 Hypothermia < 35°C
 Suspicion of meningitis
 ADULT TRIAGE SCORE ADULT TRIAGE / SYNDROMIC COMPLEMENT
COLOR /
3 2 1 0 1 2 3 CATEGORY
RED YELLOW GREEN

Stretcher SCORE 5 OR MORE 3-4 0-2

Mobility Walking With help Mobility TARGET TIME
immobile IMMEDIATE < 1 HOUR < 4 HOURS
TO TREAT
RR <9 9 - 14 15 - 20 21 - 29 > 29 RR MECHANISM
HIGH ENERGY TRANSFER
OF INJURY
HR < 41 41 - 50 51 - 100 101-110 111-129 > 129 HR BREATH SHORTNESS - ACUTE

COUGHING BLOOD
SBP < 71 71 - 80 81 - 100 101-199 > 199 SBP
CHEST PAIN
SEIZURE - CURRENT
temp < 35 35 - 38,4 > 38,4 temp SEIZURE - POST ICTAL
Reacts to Reacts to Unresponsi HAEMORRHAGE -
AVPU Confused Alert AVPU HAEMORRHAGE CONTROLED
voice pain ve UNCONTROLLED

Trauma NO YES Trauma FOCAL NEUROLOGY - ACUTE

REDUCED LEVEL OF
age > 12 years / taller > 150 cm
CONSCIOUSNESS
THREATENED LIMB
DISLOCATION FINGER OR
DISLOCATION OTHER JOINT
TOE
FRACTURE - COMPOUND FRACTURE - CLOSED

PRESENTATION
BURN - FACE / INHALATION
ALL OTHER PATIENTS
BURN > 20%
BURN - ELECTRICAL BURN : OTHERS
ROUTINE: BURN - CIRCUMFERENTIAL
VITAL SIGNS APPROACH BURN - CHEMICAL
POISONNING / OVERDOSE
HYPOGLYCAEMIA -
PSYCHOSIS / AGRESSION
glu<3mmol/l or 0,6g/l

DIABETIC - glu>11mmol/l DIABETIC - glu>17mmol/l

or2g/l WITH KETNONURIA or3g/l NO KETNONURIA

VOMITING - FRESH BLOOD VOMITING - PERSISTENT

PREGNANCY & ABDOMINAL

PREGNANCY & TRAUMA
TRAUMA
PREGNANCY & ABDOMINAL
PREGNANCY & PV BLOOD
PAIN
PAIN SEVERE MODERATE
COLOUR PA TIENTS Mass casualties incident
IMMEDIATE (ABSOLUTELY URGENT)
Patients who need IMMEDIATE surgical or medical treatment; their condition
is life-threatening in the short term, but they have a reasonable chance of
RED survival.
 Airway obstruction: neck or facial injuries, chest wounds, etc.
 Respiratory distress: tension pneumothorax, hemothorax, cardiac
tamponnade, flail chest, etc.
 Active bleeding with hemorrhagic shock: extremity wounds,
abdominal wounds, etc.
 Hypovolemic shock/dehydration: e.g., cholera epidemic.
This list is not exh austive

DELAY ED (RELATIV ELY URGENT)

YELLOW

Patients who need surgical or medic al treatment, but whose condition is not
immediately life-threatening, and who are stable enough to wait.
 Chest or abdominal wounds or trauma without respiratory distress
 Wounds or tra uma without hemorrhagic shock; hemodynamically
stable.
 Head trauma with good prognosi s (Glasgow Coma score >8)
 Open fractures or traumatic amputations, suspected pelvic o r
femoral fracture.
 Large wounds with no active bleeding.
This list is not exh austive

MINOR (NOT URGENT)

Patients who need non-urgent care, with no short- or medi um-term life-
GREEN

threatening conditions.
Conscious patients.
Patients who do not need hospitalisation, but just outpatient treatment.

 Superficial wounds

 Closed fractures

This list is not exh austive

DEAD OR DYING

Patients who have died, or whose condition is life-threatening and who have
very little chance of survival, with or without medical or surgical care.
BLACK

 Severe multiple trauma

 Severe head trauma (Glasgow Coma score <8), or penetrating head

trauma

 Traumatic quadriplegia
st
 Burns over more than 50% of the body (unless 1 degree)

This list is not exh austive

 TRIAGE TECHNIQUES
Simple START
Triage
And
Rapid
Treatment
* In initial START Assessment mark with triage ribbons,
but only provide minimal treatment. Only two
interventions: (1) open the airway and (2) stop excessive
bleeding. START assessments should only last 15-30
seconds per patient
1. Get up and walk

-Have patients move to safe location outside triage area that can
-Self defined green patients
2. Respiration: check for respiratory compromise

-not breathing after reposition airway = BLACK

< 30 breaths/minute = RED
> 30 breaths/minute = CONTINUE
3. Perfusion (pulse, circulation): radial pulse check

-weak, irregular or no radial pulse = RED

-strong radial pulse = CONTINUE
4. Mental Status

-fails to follow simple commands (mental status altered) = RED

- follows simple commands = YELLOW
 EMERGENCY ROOMS
ORGANISATION: Medical care area
ER = severe patients management (trauma++)
ER = ADAPTED RESOURCES NEEDED
(++ considering good quality of surgery / anaesthesia)
– Resuscitation zone / red zone :
• Specific material: automatic BP, vacuum, electrical syringe driver…
• Resuscitation material and drugs
• Dedicated HR?
– Yellow zone: acute patients / no needs of resuscitation
– Green zone: non seriously sick patients
– Plaster and suture: dedicated room or trolley.
– Isolation room?

Link +++ with OT, radiology, ICU, lab, wards : central position

ORGANISATION: Observation room